Allergy Society of South Africa

Allergy Conditions

Food - Coeliac Disease (Gluten Enteropathy)

What is Coeliac Disease
 

Coeliac Disease is also called Gluten Enteropathy, and has until recently also been known as Gluten Intolerance, though this is in fact a misnomer. CD is an hereditary disorder of the immune system in which eating gluten in foods leads to leads to damage of the mucosa (lining) of the small intestine (small gut). This results in malabsorption of nutrients and vitamins. CD is the result of IgA and IgG antibody responses to gluten. Gluten is found in wheat, rye, oats and barley.


It is important to differentiate between Coeliac Disease (mediated by IgA and IgG antibodies) and wheat allergy that is mediated by IgE antibodies. For further information on Wheat Allergy see the ALLSA Patient Information Sheet on "Wheat Allergy".

 

How common is Coeliac Disease?

 
Coeliac Disease is more prevalent than previously believed and is frequently under-diagnosed, particularly in adults who may present with subtle symptoms. In some countries the incidence is as high as 1 in 200 (Sweden) or 1 in 10,000 (Denmark). The incidence in South Africa has not been ascertained, although it is most probably under-diagnosed.


Coeliac Disease is one of the commonest life-long disorders in Western countries. The prevalence of this condition is increased in a number of conditions, such as insulin-dependent diabetes mellitus, Down's syndrome, selective IgA deficiency and certain auto-immune disorders (e.g. thyroid disease, Addison's disease, rheumatoid arthritis, Sjogren's disease).

 

What are the symptoms of Coeliac Disease?

 
The condition usually manifests in the first few years of life following the introduction of cereals into the diet. However, due to a greater understanding of the disease process and the more widespread use of the blood tests, increasing numbers of cases are being detected first in adulthood.


Typical cases of CD present at the age of 6-24 months with symptoms of intestinal malabsorption, impaired growth, abnormal stools, abdominal distension, muscle wasting, hypotonia, poor appetite or unhappy behaviour. In adults, the symptoms of CD may be highly varied and range from severe weight loss and diarrhoea with bulky offensive stools, to subtle complaints of cramps, abdominal bloating, flatulence and even constipation. These individuals are often mistakenly diagnosed as having an irritable bowel syndrome. Recurrent oral aphthous ulcers are common and should arouse suspicion of the condition.


Dermatitis herpetiformis is a variant of Coeliac Disease in which clusters of itchy blisters occur, usually over the buttocks, knees and elbows.


On the other hand, gluten allergy (which is IgE-meditated can manifest later in life with a wide range of presentations. Atypical manifestations include intestinal complaints such as recurrent abdominal pain or extraintestinal manifestations such as short stature, persistent iron-deficiency anaemia, folate deficiency anaemia or a calcium metabolism disturbance.

 

How is Coeliac Disease diagnosed?

 
There are a range of blood tests that have been introduced internationally over the past few years that can be used to support the diagnosis of CD.

  • 1. The anti-gliadin antibody (AGA) assays
    • (a) for IgA against gliadin, that measures the amount of IgA antibody produced against the gliadin component of cereals
    • (b) for IgG against gliadin, that measures the amount of IgG antibody produced against the gliadin component of cereals.
  • 2. The anti-reticulin antibody (ARA) test, (that is based on IgG antibodies seen in an Immuno-Fluorescent microscope examination)
  • 3. The anti-endomysial antibody (AEA) assay, that identifies IgA antibodies against the endomysium tissue.


These tests offer simple and fast tools to investigate patients with suspected CD. They are particularly recommended for selected screening of risk groups, such as relatives of CD patients, undiscovered CD patients, and patients who are affected by a related disease such as malabsorption or diabetes mellitus. These tests, and in particular the AGA assays, are also very useful in monitoring the compliance to a gluten-free diet, as any increase in the levels of the antibodies indicates exposure to gliadin in the diet.


These assays are available at a number of private pathology laboratories throughout South Africa.


The widespread use of these tests has shown not only that CD is relatively common in Western countries but that it is characterised by a higher degree of clinical variability than previously thought. However, none of these assays have shown 100% accuracy in diagnosing the condition.


The small intestinal mucosal biopsy therefore remains the cornerstone for diagnosis and any provisional diagnosis of Coeliac Disease must be confirmed by this biopsy. The procedure is safe and usually performed at the time of gastrointestinal endoscopy. However, the sampling variations sometimes require several biopsies.

 

Treatment of Coeliac Disease

 
The first line of treatment is the complete removal of gluten from the diet. This usually entails life-long avoidance of all cereals containing gluten, including wheat, oats, rye and barley. Individuals on any avoidance diet are at risk of developing deficiencies of micro-nutrients (e.g. thiamine, riboflavin, niacin, iron, selenium, chromium, magnesium, folacin, phosphorus and molybdenum). It is therefore essential that patients with gluten allergy be managed in collaboration with a dietitian. Information on gluten-free diets is becoming increasingly available worldwide. Gluten free products are also becoming more abundant and more easily available.

For more information:

  • The Gluten-Free Guide for Southern Africa by Carole Smollan, Delta Books, Johannesburg, South Africa, 1997.

  • The Website of Laboratory Specialities at http://www.labspec.co.za

  • The Coeliac Support Group
    www.labspec.co.za/coeliac/index.htm
    Ms Lucille Cholerton
    Chairperson: Gluten Intolerance/Coeliac Support Group
    Tel: (031) 764 2129 or lucoll@mweb.co.za
    1, The Palms
    13, Park Lane
    Kloof 3610
    South Africa